The Super Six model:
Integrating diabetes care
across Portsmouth and
south‑east Hampshire
Partha Kar
Article points
Within a given community, the level and quality of care for
people with diabetes, in light of the complex nature of the
condition, is of great importance. Recently, there has been a
drive towards increasing skill and knowledge in primary care
and moving away from the traditional model of all diabetes care
being delivered in a specialist setting, often met with conflicting
views. This article presents a new model that bridges the divide
between primary care physicians and specialists, allowing
primary care teams to function within an extended clinical
professional domain in their community setting.
I
n September 2009, a number
of challenges were faced within
the diabetes healthcare world of
Portsmouth. This included the need for a
cost-improvement programme and demand
management, as well as the transition
of services to primary care and doubt
amongst GP colleagues about the need for a
specialist centre. These challenges, coupled
with the perception from nurse colleagues
that primary care was not sufficiently
equipped and the cynicism of specialist
colleagues within the hospital due to past
experiences with primary care trust (PCT)
commissioners, led to an increasing worry
about the future of diabetes speciality.
It was time to take stock and to assess
what worked. As a first step, the diabetes
team met with a team of nurses, dietitians,
administration
staff
and
consultant
colleagues. Advice was also sought from
the local GPwSI, who clearly had the drive
Diabetes & Primary Care Vol 14 No 5 2012
to improve diabetes care, the community
nurses struggling with the sheer demand
from primary care and, finally, a number
of practice nurses and other primary care
colleagues battling the “tide” but never
shirking away from the basic tenet of
trying to help. From these discussions, it
was difficult to ascertain why all of these
passionate individuals, all of whom wanted
to help, could not quite work together. Of
course, history had a part to play, as relics
remain from the time where consultants
were the “be-all and end-all” within a
traditional model and anything mildly
complicated was sent to the hospital, in
which everything could be “sorted”.
But times were changing and specialists,
perhaps nationally, appeared to have
failed to adapt quickly enough. Primary
care training had changed and successive
governments made clear policies to
decentralise the bulk of chronic disease
1.The author sought to
improve the service of
care offered to people
with diabetes in the
community.
2.It was agreed that six clear
areas would fall under the
remit of the acute trust,
that is the “Super Six”.
3.A new model of
integrated primary and
secondary care was
implemented.
4.As a result of the
changes, 90% of patients
were discharged from
secondary care, many
transferred to “Super Six”
clinics and the number of
general diabetes referrals
reduced significantly.
Key words
- Community
- Diabetes specialist
- Primary care
Partha Kar is
Clinical Director of
Endocrinology/Diabetes
at Portsmouth Hospitals
NHS Trust, Hampshire,
and NHS Diabetes
Innovation Lead.
277
The Super Six model in Portsmouth and south-east Hampshire
Page points
1.An initial assessment
was completed of the
challenges and problems
faced within diabetes
care in Portsmouth and
south-east Hampshire.
2.It was deduced that two
different systems were
being used, resulting in
a post-code “lottery” in
regard to the level and
quality of care received
by different people with
diabetes.
3.Discussions were
underway to identify
which areas of diabetes
needed to be under
specialist care, giving rise
to the “Super Six”.
work, but somehow specialists got “left
behind”, still clinging on to the belief that
it would be “OK”, rather than adapting
to help primary care deal with the
increased complexity and help the patient.
Governmental pressure led PCTs and PCT
managers to force care into the community,
leaving primary care with more to do.
The easier option seemed to be to criticise
either the managers or primary care, while
our primary care colleagues were either
divided into a majority of “We never asked
for this” or a minority of “I can do it all.”
No doubt, it was time for change. It was
time to at least try.
Assessment of problems
with diabetes care
Firstly, the structure and situation of the
specialist centre was assessed. The centre
had a population base of approximately
650 000, including approximately 30 000
people with diabetes across a widespread
area with significant socioeconomic
variations. There were two PCTs, based
in south-east Hampshire and Portsmouth,
respectively, each using different methods
of delivering diabetes care. In south-east
Hampshire, a community diabetes team
was present, comprising 1.6 whole-time
equivalent (WTE) Band 7 nurses, along
with one session per week of a GPwSI,
whose role was to support primary care
for people with diabetes. Contrastingly, in
Portsmouth, a “traditional” model was in
place where any referrals were made to the
specialist centre for review and opinion.
Thus, both for the specialist team and
the patients, two different systems
were being used, creating a post-code
“lottery” in regard to the level and quality
of care.
The Hampshire commissioners had
not seen the need for any consultant
input when the Community Diabetes
Team (CDT) was created in 2007, while
Portsmouth commissioners had opted to
stay away from an intermediate team. The
pressure of demand management continued
to rest on the acute trust, thus placing
the specialist team under pressure from
internal managers, whilst clinical concerns
from medical and nursing staff within
the diabetes specialist team prevented
patients from being discharged. This
clinical concern centred on the capability of
primary care to be able to handle diabetes
patients with increased complexity.
Box 1. The Super Six.
lInpatient
diabetes
diabetes
lDiabetic foot care
lDiabetic nephropathy
(patients on dialysis or with progressive decline of renal function)
lInsulin pumps
lType 1 diabetes (poor control or adolescent)
lAntenatal
Box 2. Community role of the consultant team.
lDedicated
phone line between 17.30 and 19.00 5 days per week for GPs and practice
nurses
lDedicated email – accessed by other members of community team and for GPs and
practice nurses
lBi-annual visits to GP surgery
lContribution to local medicine management meetings
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Diabetes & Primary Care Vol 14 No 5 2012
Taking things forward
Multiple meetings were set up with GP colleagues,
the CDT and healthcare providers in an effort to
understand what could be changed. Engagement
with GP colleagues and practice nurses was achieved
by visiting their surgeries, inviting them out socially
and attempting to impress upon them that specialist
diabetes care in Portsmouth was ultimately centred
on helping the patient and did not involve all patients
being seen inside the setting of the hospital. The basic
principle was that specialists had two distinct roles,
the “super specialist” and the “educator”, as a support
mechanism for primary care.
Discussions were initiated to identify which areas
of diabetes needed to be under specialist care either
owing to the multidisciplinary nature of clinics,
such as antenatal diabetes clinics, or in areas where
specialist expertise was beyond dispute, such as the
use of insulin pumps. This gave rise to the “Super
Six”, in which six clear areas were identif ied by all
concerned that needed to be under the auspices
of an acute trust, either due to the higher level of
expertise involved or the multidisciplinary nature
of the clinic set-up (Box 1). It was agreed that all
other patients be discharged back to primary care
with the understanding that their cases could be of
higher complexity and recognising that expertise
and resources were variable in primary care.
This was the area in which the expertise of the
specialists as educators was to be used. Discussions
were held to clarify how this role would work
in practice and involved various methods of
communication (Box 2).
Apart from the use of phone and email, there were
regular visits to practices which would complement
the existing contact from the community nurse
specialists and the onus was shifted on how to best
utilise the practice visits. Various options were
suggested but the key to this was flexibility and
allowing the surgeries concerned to choose, rather
than enforcing a plan or model (Box 3). The idea
was for primary care to use the case(s) discussed as
learning opportunities that could create a “ripple
effect” whilst dealing with cases of similar complexity.
Financial modelling was relatively simple. To the
commissioners, the savings were to be realised by
discharging patients who did not fit into the Super
Six. The number of new referrals was also expected to
decline, as general referrals were deemed to be suitable
Diabetes & Primary Care Vol 14 No 5 2012
The Super Six model in Portsmouth and south-east Hampshire
“The role of the
diabetes team to the
trust was clearly
defined, thus also
clarifying the roles
of the specialist
nurses within the
department as they
had designated
areas or streams
to lead, develop
and deliver
services in with
their consultant
colleagues.”
to be discussed as part of the community
model. The difficult part was to convince
the acute trust of this model, as the loss
of revenue would be for the acute trust to
bear. In the background was also the issue
as to which of the four consultants would
join the CDT. Thus, the concept of the
whole team of specialists working together
was mooted. The advantages were obvious,
as encouraging the four consultants to work
as a team offered a 52-week service, owing
to cross-cover, whilst employing a sole
consultant for sessions would entail a 42week service, owing to the requirement of
annual leave or study leave. There would
also be the availability of a spread of
expertise in the way of not only specialised
areas, such as the diabetic foot and type 1
diabetes in adolescents, but also leadership
and governance. The community contract,
which sat with a community provider, was
therefore expanded to include consultant
sessions via the group, whilst the nurse
workforce was bolstered to 2.5 WTE,
all achievable owing to money released
from the acute trust to the community.
Furthermore, the consultant team set up a
“Conf lict of Interest” panel with the acute
trust, Portsmouth Hospitals NHS Trust,
and three cases were put forward for the
trust to consider:
lThey had not bid for the community
services when the tender was advertised
in the past.
lClinically,
the group of patients
to be discharged were those whose
care was better provided closer to
home and any concerns about the care
were assuaged by the presence of the
consultants within the CDT who would
provide support and education to the
primary care professionals.
lFinally, and possibly most importantly,
as the team were reducing activity, they
would, as a group, also take a reduction in
their salary from the trust.
The trust agreed with the arguments put
forward and the formation was approved
of a consultant team, whose clear remit
was to deliver community care and not
to do services for which the trust was
commissioned, thereby avoiding any
conflict of interest.
The Southern Health Foundation Trust,
which held a contract for the community
team, agreed to have a sessional contract
with the consultant team. Therefore, the
drop in salary for the consultants in regard
to the acute trust was supplemented via
a contract with the community provider.
Subsequently, the commissioners sent a
letter to the trust detailing which services
the trust was to undertake. The role of
the diabetes team to the trust was clearly
defined, thus also clarifying the roles of
the specialist nurses within the department
as they had designated areas or streams
to lead, develop and deliver services in
with their consultant colleagues. Key
performance indicators were also set up in
joint consultation between the “re-vamped”
community team and the commissioners.
These included short- and long-term
indicators, in which the short term focused
on financial savings and satisfaction
surveys, whereas the longer term focused
more on outcome measures, such as the
rates of admission, myocardial infarctions
and renal dialysis.
The stage was thus set and meetings
Box 3. GP surgery visits: “Options”.
lVirtual
clinics (case-based discussions)
of database to discuss patients in regard to Quality and Outcomes
Framework targets
lReview of audits completed by surgery on diabetes care
lEducational session on area(s) of diabetes management of surgery’s choice
lPatient review (in conjunction with GP or practice nurse)
lReview
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Diabetes & Primary Care Vol 14 No 5 2012
The Super Six model in Portsmouth and south-east Hampshire
were arranged with the existing CDT to
plan the service roll-out. Discussions were
held regarding the discharge of patients,
as in neighbouring trusts there was the
cautionary tale of patients being discharged
without any consultation, resulting in
angst amongst specialists, primary care
practitioners and patients. It was decided
that clinic codes would be looked at,
particularly codes for those traditionally
labeled as “general diabetes clinics”, and
patient lists were prepared based on their
GP surgeries. Each GP surgery was then
sent the list for an opportunity to check
and ascertain from their records which
patients they considered appropriate for
discharge. Those to be discharged were sent
a joint letter signed by the GPwSI and the
consultant team, explaining the reason for
discharge and that their healthcare would
continue but in a different way, which
involved the specialists being available to
discuss the case at any point in time with
their GP or practice nurse. Those who did
not feel comfortable in being discharged
were either transferred to an appropriate
clinic (e.g. type 1 clinic) or given the
opportunity to discuss this with the surgery
on their first visit from the consultant team.
The roll-out of the new model
In November 2011, all the contracts
were signed and the service was ready
to commence. A publicity campaign
was launched from all quarters. The
consultants sent a letter to all surgeries
detailing the new diabetes care model
and the commissioners followed suit. The
community
provider’s
communication
team was used and the existing CDT
helped in publicising the new model. Any
educational events were also used as a
platform for highlighting this innovative
and new service, whilst clarifying the
referral pathway for the patients who fell
in the Super Six category. It was vital to
reinforce that existing provisions, such as
regular access to community diabetes nurse
specialists and the DESMOND programme,
Diabetes & Primary Care Vol 14 No 5 2012
were not changing and that this was simply
an addition to the service of the local
consultants.
The visits from the consultants in the
first instance involved discussing with the
surgery concerned an appropriate time
for visit. Once agreed, one member of the
consultant team attended along with a
specialist nurse colleague whilst, from the
surgery concerned, there was the presence
of, at minimum, the lead diabetes GP and
lead diabetes practice nurse, although
on most occasions, a majority of the GPs
attended. The service design was reiterated
and patients who were not deemed ready
to be discharged were discussed. Any other
patient that the GP surgery had under its
care and for whom it was felt that a review
was needed were also discussed. Of the
options available, the most popular option
amongst the different surgeries was the
offer to help with Quality and Outcomes
Framework points relevant to diabetes
patients (Box 3). A rota amongst the
consultants was constructed, which would
help to identify who would be responsible
for the phones and email contacts.
“Specialists need to
be open to working
differently and
closer to primary
care, while primary
care colleagues
need to accept that
specialists can provide
support and are
ready to do so.”
Further on
Eleven months have passed and the model
has since been rolled out to 41 of the
51 GP surgeries. A total of 712 patients
have been discharged with all records of
complaints from patients and GP surgeries
being recorded. To date, there have been
14 complaints, all dealt with individually,
of which six patients have been reinstated
while others have been reassured and
provided with more clarity about the service
on offer. One GP complaint was registered
and similarly withdrawn after service
specifications were reinforced. Patient
feedback and GP surgery feedback was also
regularly collected, especially after each
surgery visit, and the feedback has been
overwhelmingly positive. Referrals to the
general diabetes clinics have also dropped
from 14 per month to two per month.
This has allowed for clinics to be shut
281
down gradually, whilst also freeing up time for the
consultants to visit the GP surgeries and helping the
trust to reduce salaries accordingly. The GP visits have
focused on discussing patients with complex diabetes
issues, with clear records of decisions being made.
The local commissioners and CCG leads sent a
letter with positive feedback and news of targets being
hit, which has helped to enhance the reputation of the
service. As a marker of achievement, the model was
also lauded by the local trust and recognised by Sir
Bruce Keogh, Medical Director, NHS Commissioning
Board, for its financial modelling and clinical
delivery. It has also recently won the “Care Integration
Awards 2012” for diabetes care.
This model of care was then assessed by the
commissioners in Portsmouth and a community
diabetes service was tendered. This was won by the
Solent NHS Trust, which once again entered into a
sessional contract with the consultant team, with the
nurse and administration component being held by
Solent itself.
The whole of south-east Hampshire and Portsmouth
now had an identical model of care and people were
not subject to a post-code “lottery”. The consultant
team became the link across the three providers of the
area, providing the integrated care needed.
Looking back and looking ahead
There is no doubt that the road has been long in an
effort to reach this level of integrated care and there
have been the usual share of detractors, such as
specialists who have doubted the model, who have
shown reluctance to the idea of working in primary
care. However, in the end it has been possible owing
to the sum of all parts. There is still plenty to do
and much to achieve but the first steps have indeed
been taken. The specialists have redefined themselves
and support primary care colleagues to deliver highquality patient care. It is no longer about posturing or
having a debate as to who is best qualified; it is about
working as a team and utilising each others strengths
to improve diabetes care in the community. The
success of this project can be largely attributed to the
colleagues who have placed trust in the vision, as well
as a motivated GPwSI and nurse colleagues within the
acute trust and community, all focused on improving
relations and working together for the betterment of
diabetes care. It was a boon to have commissioners
and CCG leads who were willing to listen and make
Diabetes & Primary Care Vol 14 No 5 2012
changes, along with primary care colleagues who
welcomed the change initially with caution but then
always had encouraging words of hope and belief.
If there is any advice for the author to pass on to
the readership, it is not to lose belief that integrated
care is possible. Acute or community trusts are
bastions which indeed look after our contracts and
salaries, but they should not be obstacles for us to
work together in an integrated manner. This case
provides an example of how this is possible, how this
can be achieved and why a “two-way street” is needed.
It has taken time, patience and plenty of negotiation
but it has indeed been done. Specialists need to be
open to working differently and closer to primary
care, while primary care colleagues need to accept
that specialists can provide support and are ready
to do so. The term Community Diabetologist was
coined a few years back, and, ironically, created more
divisions than envisaged and perhaps this happened as
traditional hospital-based specialists stayed blissfully
unaware of the changes afoot. Today, the CDT in
Portsmouth is as much a part of the acute trust, as it
is a part of the community trust; thus, the members
are as much community diabetologists as they are
acute diabetologists. It is the author’s opinion that the
patient rarely cares who the healthcare provider works
for, but simply wants to be treated to the best of his or
her expertise.
The Super Six model was launched with the
intention of meeting the patients’ needs. Although
better options are likely to become available, such
as the Derby diabetes model of care and north-west
London integrated care, the success of the model to
date provides support for exploring different options
and welcoming change. The author is aware that
one model does not fit all. However, hopefully this
provides some tips for moving towards integrated care
and improving diabetes care overall.
n
Acknowledgement
With acknowledgement to Iain Cranston, Michael
Cummings, Darryl Meeking, Tim Goulder and the
entire diabetes specialist nurse team who the author had
the pleasure of working with, as well as the primary care
colleagues and commissioners for sharing and believing in
the vision.
Diabetes & Primary Care Vol 14 No 5 2012